1 Hessian Ministry of Economics, Transport, Urban and Regional Development Hessen Gateway to Contract Research in Europe A practical Guide to Sites and Services, second edition
3 Hessen Gateway to Contract Research in Europe A practical Guide to Sites and Services, second edition Volume 8 of the Brochure Series Aktionslinie Hessen-Biotech
4 Imprint Brochure Series 4 Hessen Gateway to Contract Research in Europe Volume 8 of the series Aktionslinie Hessen-Biotech of the Hessian Ministry of Economics, Transport, Urban and Regional Development Publisher HA Hessen Agentur GmbH Dr. Detlef Terzenbach Abraham-Lincoln-Str Wiesbaden GERMANY Phone Fax Listing of a company profile within this publication is strictly voluntary, all Contract Research Organizations in Hessen have the opportunity of being entered in this database since its online version is being continually expanded and updated. The publisher does not take any responsibility for correctness and preciseness of the give information. Brochure Series of the Aktionslinie Hessen-Biotech of the Hessian Ministry of Economics, Transport and Regional Development Volume 1 Förderoptionen Für technologie-orientierte Unternehmen in Hessen Volume 2 Werkzeuge der Natur Weiße Biotechnologie in Hessen Volume 3 Hessen: Gateway to Biomanufacturing in Europe A pracitcal Guide to Sites and Services for GMP-Production Quality Management Contract Manufacturing Volume 4 Hessen Your Gateway to the Diagnostics Market in Europe A pracitcal Guide to Services and Technology for the Diagnostic Industry Volume 5 Medizintechnik in Hessen Strukturen und Potenziale Ergebnisse einer Unternehmensbefragung Editorial Office TransMIT Gesellschaft für Technologietransfer mbh, Gießen Hessian Ministry of Economics, Transport, Urban and Regional Development Jens Krüger Kaiser-Friedrich Ring Wiesbaden GERMANY Reproduction and reprint even in parts subject to prior written approval. Volume 6 Competence Atlas Hessen-Biotech 2007 The Spectrum of Biotechnology Companies in Hessen Volume 7 Hessen das Tor zum europäischen Diagnostikmarkt Wegweiser für Dienstleistungen und Technologien in der hessischen In-vitro-Diagnostik-Industrie Volume 8 Hessen - Gateway to Contract Research in Europe A practical Guide to Sites and Services. Second edition Design ansicht kommunikationsagentur, Wiesbaden GERMANY Photos HA Hessen Agentur GmbH fotolia NiDerLander moodboard mario beauregard istockphoto.com DivaNir4a DavidBGray PhotoDisc Translations Language Service Center, Gießen GERMANY Print Werbedruck Schreckhase GmbH, Spangenberg GERMANY May 2009
5 Content Foreword 6-7 Clinical Research in Hessen Hessen 8-10 Gateway to Clinical Research in Europe Paul-Ehrlich-Institut A Federal Research and Regulatory Institute with International Competence for Vaccines and Biomedicines 5 Yes Pharma Regulatory Compliance as a Prerequisite for Lean Drug Development Sterna 17 Biotech Start-ups and Contract research Organizations Forming winning teams ZAFES Investigator-initiated trials Ethics Committees The Work of the Ethics Committees in Hessen RP Darmstadt Competence and Communication Mission Statement of the Monitoring Authority Profiles Supplement Some basics on Clinical Research
6 Foreword 6 Clinical Research in Hessen Minister of Economics, Transport, Urban and Regional Development in Hessen Health is no longer just a highly private affair, it is also a major economic factor. The health business is growing at a very considerable rate. In 2007, for example, the statutory health insurance funds in Germany spent almost 28 billion euros on medicaments alone. To secure a share in this market, companies need not only good products but also an excellent infrastructure and reliable business conditions. Unless these are available, research-based pharmaceutical companies will hardly be prepared at all to start out on the highly long-term and cost-intensive processes culminating in the authorisation of a new active ingredient. Not many regions offer excellent and reliable business conditions of this kind. The Federal State of Hessen is with certainty one of them, with its economic centre Frankfurt/Rhine-Main and its pharmaceutical industry with a tradition going back over one hundred years. It is not for nothing that the region, one of the economically most powerful centres in Europe, bears the title of Germany s chemist shop. It is now one hundred years since the first Nobel Prize winner for medicine, Emil von Behring, established the world s first biotech start-up the Behringwerke AG in Marburg and began with the production of vaccines through the immunisation of horses. In 1909, Paul Ehrlich, the Nobel Prize winner resident in Frankfurt, started on the production of the world s first chemical therapeutic agent Salvarsan for the treatment of syphilis. His success formed the basis for the rise of Farbwerke Hoechst as the world s leading pharmaceutical concern. Nowadays the pharmaceutical industry in Hessen employs over 29,000 people, who in 2008 generated a turnover of around 11 billion euros that is more than a quarter of the turnover of the entire German pharmaceutical industry. Of this, pharmaceutical products to a value of 7 billion euros were exported throughout the world from Hessen. Companies such as Sanofi-Aventis, Merck Serono, Fresenius, Novartis-Behring, CSL-Behring, Lilly, Merz or Abbott are just a few examples of internationally successful concerns researching and producing in Hessen. Biotechnology is assuming a constantly increasing share in all this. Over 200 companies are engaged in biotechnology. Most of them are service providers, whether in contract research, production, the growing field of quality management or the performance of clinical trials. This mix, covering the entire range of the pharmaceutical value chain, is unique in Europe. Important factors for the growth of companies are also created by an attractive regulatory framework. The responsibilities for implementing the requirements of gene technology legislation in Hessen were centralised in a single authority, with the result that companies need to approach only one contact partner. The times necessary for approval of new plants are among the shortest in Germany. Companies benefit from the international character of the Frankfurt/Rhine-Main region. No other region in Germany houses so many companies from abroad. More than 700 American firms are located in Hessen, and just on 20 percent of all American direct investments in Germany find their way here. Frankfurt has the largest Korean community in Europe, the Chinese and Japanese communities are growing steadily. The many international schools enable expatriates to have their children educated in same way as they would be in their own countries. This is one reason why employees of foreign companies are so willing to live here. One factor which makes the region so attractive is the excellent transport infrastructure. The Frankfurt Rhine-Main airport, with about 54 million passengers per year, is among the largest airports in Europe after London and Paris. It offers 4,375 direct flights a week to all major international centres, and to many of them several times daily. Frankfurt is also Europe s largest air freight Dieter Posch
7 Foreword transhipment centre. These connections guarantee the opportunities for rapid travel which are so important for internationally operating companies. With 40 contract research organisations (CROs), it is no coincidence that clinical research is centred in the region. It is clear that effective research, especially into the development of new therapeutic active ingredients, cannot be done without academic research and training of high quality. Here, again, the excellent infrastructure in this area becomes evident. In less than one hour it is possible to reach a large number of maximum care hospitals with about 35,000 beds. In Hessen, relevant subjects such as human medicine, pharmacy, biology, chemistry or process engineering are taught at as many as twelve universities and high schools. More than 600 professors teach nearly 17,000 students in these subjects. Every year, companies can draw on a pool of almost 3,000 highly qualified graduates. The State of Hessen has set up an Initiative for the Development of Scientific and Economic Excellence (LOEWE) with a view to establishing new leading-edge technology centres. Additional resources were made available with the explicit intention of turning already existing strong points into real centres of excellence. The maximum benefit of this will accrue to the Life Sciences. In addition to the universities and high schools, there are also the four Max Planck Institutes, where high-end research is carried out. Among their principal focuses are biophysics, physiological research, brain research and microbiology. The close interlocking of business and science, of research and application, is already producing visible results in Hessen in a nation-wide contest, Hessen was chosen to establish an excellence cluster in the promising future field of white biotechnology. This is now engaged in developing the most recent methods for the biotechnological production of fine and specialty chemicals. Backed up by these resources, Hessen is in a good position to expand its position as a biotech production industry region. The pharmaceutical concerns based here are extending their production capacities Novartis Behring in Marburg, Abbott in Wiesbaden, and Sanofi-Aventis in Frankfurt. All this speaks for the quality of Hessen in the fields of pharmaceuticals and biotechnology. This is doubtless one of the reasons why the CROs stated in their replies to a questionnaire that Hessen is unusually well positioned and can be considered as a first-class competence centre able to stand any international comparison. I would like, therefore, to invite you to use this brochure as a source of information about the opportunities for clinical testing in Hessen. I greatly hope that you will be convinced by what we have to offer and would be very glad if we could extend a welcome to your company also. Dieter Posch Hessian Minister of Economics, Transport, Urban and Regional Development 7
8 Hessen 8 Hessen: Gateway to Clinical Research in Europe Clinical research is beyond all doubt one of the most important phases in the development of a new medicament. Mistakes made at the beginning whether in the planning of the study, the choice of suitable cooperation partners or the drafting of the test schedules can lead to considerable costs and lengthen the time needed for registration. For this reason it is important for small and medium-sized biotech and pharmaceutical companies to find speedy and uncomplicated access to networks offering high-quality advisory services in connection with clinical tests and their performance. In this brochure you will find a list of the Contract Research Organisations (CROs) in Hessen and the test centres at Hessen s university clinics. Access to 500 million consumers Hessen, with its economic centre Frankfurt, is one of the centres of the European chemical and pharmaceutical industry. It is ideally situated in the middle of a pharmaceutical market with 500 million consumers. These are joined by just on another 300 million consumers in the non-eu Eastern European states. These countries, which include Russia and the Ukraine, are noted for their high concentration of hospitals and practising physicians. Region USA European Union (27 States) Eastern Europe Consumers 283 million 501 million 300 million Eastern Europe. This was made very much easier by the history and culture shared by European countries. Next to Russian, German is the most widespread foreign language in Eastern Europe. Hessen - The centre of the CROs in Germany More than 40 CROs are based in the region around Frankfurt. In addition, there are many providers who help to ensure the quality of testing either by consultancy services in this context or through the provision of software and quality management products. These CROs employ 1,700 people in Hessen, and more than 38,000 worldwide. This indicates how well Hessen s CROs are netted globally and what potentials this centre has to offer. A look at the adjoining map (illustration with the dots on the Hessen map) will clearly show how greatly these companies can benefit from the geographical nearness to the authorities and the transport connections. CROs give the region an excellent rating The CROs based in Hessen have stated with conviction that they are entirely satisfied with Hessen as a location. They rate it better than other German regions and consider it to be fully competitive at international level. Hessen scores very well most especially for qualified personnel and for cooperation with the authorities. It is the internationally active CROs which have given the best ratings here. They emphasise in particular the transport infrastructure and the cooperation with the ethics commissions. This can be taken as evidence for the high quality and professionalism in Hessen. All these markets can be reached from Frankfurt in less than two to three hours. Compared with the USA, a greater number of patients can be reached over a smaller area. These facts are becoming increasingly important in the growing markets of Eastern Europe because, before new medicaments are approved in these countries, the authorities expect to receive data which have been generated there. Thanks to the numerous local CROs, and also to transport facilities unequalled anywhere in Europe, 800 million consumers/patients can be reached by air in less than three hours. The CROs based here already have very close contacts with
9 Hessen The region offers the best conditions for finding qualified and well-trained personnel. The longstanding structures of medium-size and large companies, together with the high concentration of research facilities, are constantly producing a large number of highly qualified employees. Coordination centres for clinical research which have been set up at the universities act as direct contact partners. New study courses have been initiated for qualifying as study nurses or research physicians. The universities in Hessen have adapted their courses to fit in with the internationally customary master and bachelor degrees. This will ensure greater relevance for everyday practice. Hessen is one of the first German states to have reorganised and simplified the work of the ethics commissions. Multicentric studies can be set in motion much more rapidly through the binding vote of an executive committee. A standard format has been agreed on, and the work is closely supervised by Hessen s Ministry of Health. Unbureaucratic access to authorities Hessen s central situation makes it an ideal location for clinical tests. The Paul Ehrlich Institute (PEI), one of Germany s leading authorisation authorities and at the same time an internationally renowned research centre, is situated very near to Frankfurt airport. It is competent for the particularly innovative recombinant drugs, for gene therapy and stem cells. This close vicinity is of great advantage for the CROs. The PEI actively seeks contact with the CROs and sponsors, it offers advice at every stage of the application process, and provides training programmes for research physicians. The PEI is integrated in the work of the German and European regulatory authorities by voicing recommendations and also by offering advisory support for the legislature. Bonn, just over an hour s journey from Frankfurt, is the seat of the Federal Institute for Drugs and Medical Devices (BfArM), the German regulatory authority,. The European regulatory authority EMEA, based in London, can be reached by air in just under one and a half hours. Once the studies have been authorised, they are supervised by a central authority in Hessen with experts of its own who have themselves gathered extensive experience in the pharmaceutical industry. The CROs have given Hessen a very high rating at international level for cooperation with the authorities. Frankfurt Germany s centre for CROs The highest concentration of CROs in Germany lies within a one hour s drive from Frankfurt. The companies in this area are distinguished by their great variety and by the comprehensive range of services they have to offer. Practically all use areas are covered, and many of the companies are highly specialised. This high degree of professionalism is enhanced by the close networking of the CROs. More than half of the CROs work on a cooperative basis. As the most important customer group, the large pharmaceutical concerns play a major role. However, the small pharmaceutical and biotech firms are becoming an increasingly important target group. In the meantime, more than half of the CROs have gained intensive experience with small biotech firms. Operating conditions like these are highly useful especially for biotech firms newly breaking into the European market. The Hessen-based CROs are innovative, and they are striking out on new paths. A service offered by one third of the CROs is to take over the entire preparation and handling of the CTD (Common Technical Document) and forward it to the regulatory authorities in electronic form (ectd). Hessen Gateway to Europe 9
10 Hessen 10 A large number of companies, engaged up to now in the classical tasks of supporting clinical studies for new medicaments, have now turned additionally to medical products or even specialised in them. These new fields of business also include studies for the food industry to deal with health claims in connection with functional foods. Access to clinics in Hessen Investigator-initiated trials are assuming increasing importance. As many as one quarter of the CROs stated them to be their major focus, or have declared universities, university clinics and scientific study groups as their clientele. This reflects the high quality and creativity of medical research at Hessen s universities and institutes. The Centre for Drug Research, Development and Safety (ZAFES) is a model project in the southern region of Hessen in which 24 clinics and research institutes and the locally based pharmaceutical companies have joined forces under the aegis of the Frankfurt University Clinic. In the field of clinical research, they offer a complete package of clinical services over all phases of the project. This encompasses a variety of different things, ranging from chemical analysis to the provision of beds in individual clinics. CROs in Kassel Hessen The central contact partner for the university clinics in Marburg and Giessen is the Coordination Centre for Clinical Trials (KKS), which also makes important contributions in the area of personnel training. The most recent legal and professional aspects are integrated in the training of research physicians, study directors or study nurses. Hessen: Your Gateway to Clinical Research in Europe Germany remains the European reference market for therapeutic agents. It is here that the specifications for other European markets are very largely set. A number of unique advantages makes Hessen the ideal starting point for access to this enormous market. What sets Hessen apart are the best travel connections in Continental Europe, the close cooperation with all authorities, and the wide choice of highly qualified and motivated employees. In addition to its excellent resources in the area of clinical research, Hessen can offer more than one hundred years of pharmaceutical experience. And with regard to research, scale-up, production, distribution or marketing, there is hardly another region which can bear comparison with Hessen. Hessen-Biotech is your contact partner for integrating you in this network. This brochure gives you all the information you need. Dynamic companies need an environment to match, and we will open up the way for you. Kassel Bonn BfArM Marburg Giessen Wiesbaden PEI Frankfurt Mainz Darmstadt Würzburg Heidelberg
11 International Competence for Vaccines and Biomedicines The development of a medicinal product and its establishment in standard medical use is a complex process which includes research and discovery, non-clinical development, testing in clinical trials, finally marketing authorisation and post-marketing follow-up. The development process is legally regulated to ensure safety and efficacy of new medicines for maximum benefit of the patients. Non-clinical testing allows insight into the pharmacology and toxicology of a new medicinal product. Clinical testing for safety, optimal or feasible dosing, environmental risks and efficacy in controlled clinical trials provides data for a thorough riskbenefit assessment. An acceptable risk-benefit ratio is the basis for marketing authorisation, for either Germany only or also for other EU member states. Scientific research provides the necessary know-how for the experimental testing and evaluation of biomedicines. A modern research and regulatory institute like the Paul-Ehrlich-Institut therefore carries out experimental scientific research on an internationally competitive level and is a major player in the European network of medicinal product regulatory agencies. In Germany, human medicinal products are regulated by authorities of the Laender and by two higher competent authorities. While the Federal Institute for Drugs and Medical Devices (BfArM) is concerned with chemical medicinal products, many recombinant proteins, cytokines and medical devices, the Paul-Ehrlich-Institut in Langen near Frankfurt/Main is responsible for vaccines and biomedicines. Within the network of EU member state agencies, the Paul-Ehrlich- Institut provides expertise to the European Medicines Agency (EMEA), for example by assessing centralised marketing authorisation applications and by contributing to scientific advices. Furthermore, scientists from the Paul- Ehrlich-Institut are experts frequently consulted by and active in international organisations such as the World Health Organisation or the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). Due to its experience in the area of blood products and in vitro diagnostic tests for pathogens, the Paul-Ehrlich-Institut has been designated WHO Collaborating Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices in Within this function, the Paul-Ehrlich-Institut supports the WHO in the organisation of training courses and meetings, and also organises and performs laboratory studies and standardisation exercises in order to establish internationally accepted test standards. This ensures a harmonized global view on the safety and efficacy of medicines and their optimal regulation. Paul-Ehrlich-Institut: A Federal Research and Regulatory Institute with International Competence for Vaccines and Biomedicines Jens Reinhardt, Evelyne Kretzschmar, Klaus Cichutek Regulatory activities of the Paul-Ehrlich-Institut Marketing authorisation of safe and efficacious biomedicines The Paul-Ehrlich-Institut is the Federal Institute for vaccines and biomedicines in Germany. Biomedicines are derived from biological organisms and include vaccines, allergens, blood products, sera and monoclonal antibodies, gene therapy, cell therapy and tissue engineered products as well as classical tissue preparations. The Paul-Ehrlich- Institut carries out important regulatory activities on the national level such as authorisation of clinical trials, marketing authorisation, experimental and batch release testing of biomedicines and pharmacovigilance (see below). Moreover, the Paul-Ehrlich-Institut plays an important role in regulating biomedicines on the European level. Here, the European Medicines Agency (EMEA) in London co-ordinates the centralised procedure for marketing authorisation and provides scientific advice during medicinal product development. The scientific assessment of the centralized marketing authorisation applications, which contain all data collected and evaluated during medicinal product development, are conducted by experts from the Paul-Ehrlich-Institut and other EU member state regulatory authorities. The proposal for authorising marketing The buildings of the Paul-Ehrlich-Institut in Langen near Frankfurt/Main. 11 The Process of Drug Development Research and Discovery Development - Non Clinical Tests (Cell Culture, Animal Studies) - Clinical Trials (Patients) Phase I Phase II Phase III Marketing Authorisation Application Postmarketing Activities
12 International Competence for Vaccines and Biomedicines 12 National Level Regulatory Activities of the Paul-Ehrlich-Institut Clinical Trial Authorisation Scientific Advice Marketing Authorisation Pharmacovigilance Inspections / Contribution to Inspections Batch Control European Level Contribution to Working Parties of a new medicinal product is made by the Committee for Medicinal Products for Human Use (CHMP) at the EMEA followed by provision of the marketing authorisation by the European Commission. An expert from the Paul-Ehrlich- Institut is a co-opted member of the CHMP. A single marketing authorisation application to EMEA allows marketing of a new medicinal product in all EU member states and thus standard use in medical care. Experts from the Paul-Ehrlich-Institut are also members in most of the currently 12 Working Parties that support the CHMP. The Paul-Ehrlich- Institut is involved in up to 50 % of all procedures coordinated by the EMEA concerning these biomedicines. Furthermore, the co-opted CHMP member from the Paul-Ehrlich-Institut is also a member of the newly formed Committee for Advanced Therapies (CAT). The CAT will play a central role in the assessment of innovative medicines such as gene therapy, somatic cell therapy and tissue engineered medicinal products, which are termed advanced therapy medicinal products (ATMPs). Research Activities of the Paul-Ehrlich-Institut Research Groups Medical Biotechnology Virology Microbiology Veterinary Medicine Immunology Allergology Hematology & Transfusional Medicine Research areas Experimental Vaccines, Experimental Therapies and Diagnostics Host interaction with pathogens and retroelements Immune activation and evasion Safety, Efficacy and Quality of Biomedicinesedicine Scientific Advice supporting rapid and efficient biomedicines development As the complexity of biomedicines differs considerably from chemical drugs, the conventional test methods used for the final chemical drug product are often not appropriate for biomedicines and they also vary depending on the nature of the given biomedicine. Therefore, the regulatory requirements for biomedicines need to be more flexible and different testing strategies may be applied. However, this flexibility may create uncertainty in whether a chosen development and testing strategy will be appropriate. To address this uncertainty, the Paul-Ehrlich-Institut provides guidance and scientific advice to pharmaceutical or biotechnological companies and academic research groups to their medicinal product development. Scientific advice at the Paul-Ehrlich-Institut is provided during an open and informal discussion meeting where product experts from the Paul-Ehrlich-Institut meet face to face with applicants to discuss all scientific and medical topics relevant for biomedicine development, clinical testing and marketing authorisation. One of the experts of the Paul-Ehrlich-Institut is also a member in the Scientific Advice Working, which coordinates the scientific advice provided by EMEA. The EMEA scientific advice focuses on technical requirements and development strategies presented by the pharmaceutical company with a view to a future centralised marketing authorisation. Furthermore, for ATMPs of small or medium-sized enterprises, the newly established CAT will also certify the data collected on the quality and non-clinical pharmacology-toxicology of a new product. Certificates are intended to allow these companies to get additional support, also financially, for their product development. Clinical trial authorisation As a pre-requisite to marketing authorisation, biomedicines, just like all medicinal products, are tested in controlled clinical trials. Initiation of clinical trials of biomedicines in Germany requires a positive appraisal by the local ethics committee and authorisation by the Paul-Ehrlich-Institut. The applicant has to provide data on quality and nonclinical studies that support safety and provide a proof of concept for the medicinal product, which has to be in accordance with the current state of scientific knowledge. To facilitate successful clinical trial applications, the Paul-Ehrlich-Institut has issued a guidance document termed Third Notification on the Clinical Trial of Medicinal Products for Human Use, jointly published with the BfArM. Here, the requirements of the German Medicinal Product Act and references to the relevant EMEA
13 International Competence for Vaccines and Biomedicines guidelines are laid down to reflect the current state of scientific knowledge. Pharmacovigilance The Paul-Ehrlich-Institut is also responsible for the pharmacovigilance of biomedicines. The adverse effects of medicinal products, observed by and collected from healthcare providers, pharmaceutical industry and patients, are continuously monitored and evaluated to identify unexpected adverse reactions associated with medicines in order to prevent harm from patients. Necessary actions are taken by the Paul-Ehrlich- Institut or coordinated in conjunction with other authorities. Thus, by continuously monitoring risk-benefit, the Paul-Ehrlich-Institut ensures the safety and efficacy of medicinal products, thereby contributing to patient safety and public health. Official biomedicines control by experimental testing of medicinal products Vaccines and some other biomedicines require that each new production batch has to be tested or assessed and officially released by the Paul- Ehrlich-Institut before it may be marketed. The Paul-Ehrlich-Institut also carries out experimental testing of some centrally authorised medicinal products. Experimental testing of biomedicines by a governmental authority parallels in-process control and release testing by the manufacturer to ensure the quality and efficacy of each individual product dose. For vaccines, for example, this provides a high level of confidence for patients and public health because vaccines with low efficacy would not protect individual recipients from infectious disease, nor would they inhibit spread of infectious diseases in a population. Unsafe vaccines would possibly harm healthy individuals and children receiving vaccines to protect their health. Research at the Paul-Ehrlich-Institut Right from the beginning the Paul-Ehrlich-Institut has focused its research on applied and basic topics related to biomedicines. This goes back to its founder, Paul Ehrlich, whose fame is based on his success with experimental testing of diphtheria toxin as a biomedicine and on his visionary contributions to immunology. Currently, the different research groups at the Paul-Ehrlich-Institut are working in four main areas in the field of experimental vaccines, therapies and diagnostics, scientists study, e.g., the mechanisms of gene transfer and cell therapy medicinal products. Host interactions with pathogens and retroelements are important because understanding the mechanisms by which different pathogens cause diseases may lead to novel treatment and prevention strategies. Studying immune activation and evasion fosters a better understanding on how the immune system is activated to respond to pathogens. This knowledge may also contribute to vaccine development against novel targets such as certain viruses or tumours. Another area of the research in the Paul-Ehrlich-Institut focuses on safety, efficacy, and quality of biomedicines by developing and validating novel test methods for the appropriate examinations of biomedicines. This is particularly important for innovative medicinal products, and for new emerging diseases. An illustrative example for research performed at the Paul-Ehrlich-Institute is the development of new lentiviral vectors for gene transfer. The idea of gene transfer is to treat inherited diseases by replacing the defect gene with a functional copy of this gene. Lentiviral vectors are frequently used for these genetic modifications since they can enter cells of the haematopoietic system. Current safety and efficacy limitations of these viral gene vectors are for example due to the broad range of cells that can be infected. Paul-Ehrlich-Institut researchers are engineering lentiviral vectors to restrict the gene transfer to a targeted cell population of interest. This work not only helps to facilitate gene transfer, but also contributes to the understanding of the possibilities and challenges with which the manufacturers of gene therapy products are confronted. The Paul-Ehrlich-Institut also develops tools to assure the safety of biological and biotechnological medicinal products. As already described, the Paul-Ehrlich-Institut performs official experimental batch testing for biomedicines such as immunoglobulins or vaccines, independent of the manufacturer, thus providing an essential contribution to the safety of the biological medicinal product. The experimental research conducted at the Paul- Ehrlich-Institut is an indispensable basis for the fulfilment of its duties, ensuring excellent knowledge and expertise of the scientific staff, to base their assessment of the dossiers of biomedicines on first-hand research experience. It also allows the Paul-Ehrlich-Institut to provide health policy decision-makers with competent expert advice on biomedicine-relevant issues. Authors Dr. Jens Reinhardt Dr. Evelyne Kretzschmar Prof. Dr. Klaus Cichutek Biotechnology Paul-Ehrlich-Institut (PEI) Paul-Ehrlich-Straße Langen GERMANY Phone Fax Dr. Jens Reinhardt Dr. Evelyne Kretzschmar Prof. Dr. Klaus Cichutek
14 Regulatory Compliance 14 Regulatory Compliance as a Prerequisite for Lean Drug Development Dr. Julia Wellsow When developing a drug product, every company aims for a lean development process, which is focused on the target to obtain an international marketing authorisation within the shortest possible time. One important measure speeding up the development and authorisation process is ensuring regulatory compliance as early as possible during drug development. How can external regulatory experts help ensure regulatory compliance? At the latest when the proof-of-concept has been established for a new drug, the following steps including preclinical and clinical studies will need careful planning. Very often a first-inhuman Phase I study is seen as a first milestone to be reached. In most cases a Scientific Advice at a competent authority is useful at some stage(s) during the development process. The most suitable approach ensuring a lean development process varies from drug product to drug product, and identifying essential development steps requires substantial experience with regard to regulatory needs. Experienced regulatory consultants can help with the coordination of the development and ensure that regulatory needs are suitably considered. Author Dr. Julia Wellsow YES Pharmaceutical Development Services GmbH Bahnstraße Friedrichsdorf GEMANY Phone Fax Dr. Julia Wellsow What is regulatory compliance? Regulatory compliance means the adherence to all regulatory requirements relevant for the respective drug product throughout the complete life cycle of the drug product. This includes not only legal and marketing authorisation aspects, classically referred to as regulatory affairs, but does in fact comprise the complete package of pharmaceutical, toxicological, medical, and regulatory affairs. A vast variety of regulations, directives and guidelines exist with regard to the drug development and authorisation process in Europe. To ensure drug product approval within the shortest possible time and thus an early market entry, substantial understanding of regulatory requirements for development and for the drug authorisation processes is most important. While larger drug companies can usually afford bundling this knowledge within various departments of their enterprise, smaller companies such as biotech or advanced therapy start-ups may not have the resources to set up a modern all-in-one regulatory affairs department and therefore would most often need to rely on external consulting by specialised experts and contract organisations. Since the necessity to comply with regulatory requirements begins early on in the drug development process, it is generally advisable to integrate regulatory competence as early as possible. Biotechnological and other innovative drug products, such as e.g. advanced therapy medicinal products, present a special challenge in this respect, since the products are much more complex than small molecule products, and so are the respective regulatory requirements. At various stages during a drug products s life cycle the need will arise to submit certain documentations to the competent authorities. This is not only the actual submission of the application for marketing authorisation in CTD structure (Module 1-5), but also during the development process submissions will have to be made, e.g. before a Scientific Advice and before starting clinical studies in form of an Investigational Medicinal Product Dossier (IMPD) and an Investigator s Brochure (IB). Once the drug product is authorised, pharmacovigilance observations will need to be documented and reported. These documentations need to comply with very specific requirements, which raises the need that data are recorded and processed in compliance with these requirements as early as possible during drug development. While a large drug company might have suitable documentation systems available, this will be more difficult for smaller drug companies which may want to outsource data organisation for regulatory purposes. In the following specific aspects of regulatory compliance with regard to pharmaceutical quality, preclinical studies, clinical studies, and data documentation are discussed. Why consider pharmaceutical quality early in the development? Concerns regarding pharmaceutical quality run like a thread through the complete development process and the life cycle of a drug product. According to our long experience, these are unfortunately often missed in the beginning of the development process, which can have substantial impact on later stages of the development, particularly in the case of complex biotechnological and other innovative drug products.
15 Regulatory Compliance The pharmaceutical quality of the drug product used for preclinical studies should be comparable to the pharmaceutical quality of the drug product used for clinical studies and for the market once the drug product is authorised. Comparability in terms of pharmaceutical quality needs to be documented. This means that consideration has to be given to the pharmaceutical quality of the drug substance and the drug product before the start of preclinical studies and any modification during development must be continuously assessed with regard to their scientific and regulatory impact. One needs to be aware of the fact that the pharmaceutical quality of the drug product and the drug substance can have substantial influence on the outcome and interpretation of preclinical and clinical studies. The rationale behind it is that, for instance, the impurity profile of a drug substance or drug product may influence the toxicity and even the efficacy of a drug product. This is particularly the case for biotechnological products where the drug substance is rarely a pure protein, but often a mixture of various protein variants. The immunogenicity of a protein product may also be strongly influenced by its impurity profile. For biotechnological products, the composition of the drug substance in terms of protein variants and the impurity profile strongly depends on the synthesis and purification process. During early development of a biotechnological drug product the synthesis and purification process and the analysis of the drug substance may not have been ultimately optimised and will be subject to change at a later stage. Most often an upscale of the synthesis process has not yet taken place. The above considerations not only apply to biotechnological products, but also to the broad variety of advanced therapy medicinal products. With regard to the required comparability of drug product(s) used during the development stages, reference samples of the drug substance and drug product(s) used during all studies should be retained in order to be able to re-analyse these samples, e.g. in case more sensitive analytical methods have been developed. In case the applicant is not able to show comparability, it cannot be excluded that the authorities request that e.g. certain preclinical studies are repeated before the clinical studies can be started, and even clinical studies may require repetition. Moreover, the chosen packaging for the drug substance and the drug product needs careful consideration. In case plastic packaging materials are chosen, the drug product may need to be investigated with regard to leachables from the plastic that may have effects on the safety of the drug product. In addition, particularly with proteins administered in low doses, the observation that the drug substance is adsorbed to the plastic packaging material is not uncommon, and can result in loss of efficacy. The stability of drug substance and drug product in the chosen packaging material needs to be addressed before clinical studies can be started. Manufacture in a GMP regulated environment is mandatory for drug products used in clinical studies. In order to ensure comparability it is always advisable to start production in a (c)gmp regulated environment as early as possible. The pharmaceutical quality of the drug substance and the drug product needs to be documented within the IMPD before a clinical study can be started. The complexity of the documentation for pharmaceutical quality depends on the type of the investigational medicinal product and also on the clinical study phase. The IMPD needs to be compiled in accordance with relevant regulations and guidelines, which regulate the structure of presentation and the level of detail needed at a certain stage. When suitably planned, the IMPD can later be used as a basis for the more comprehensive pharmaceutical quality documentation of drug substance and drug product required for marketing authorisation in CTD format. What needs to be considered during preclinical development? Particularly for biotechnological and other innovative drug products the general concepts of designing preclinical studies as applicable for small molecules cannot be followed without being critically surveyed, and most often preclinical study programmes specific for the particular drug product have to be designed. This includes, for instance, choosing a relevant animal species and considering specific risks associated with the particular drug product. Close cooperation with toxicological experts is advisable. In order to plan the preclinical study design, the target disease, the route of administration, and the intended dosage regimen should ideally be known for the drug product. Since very often no specific guidelines exist for innovative biotechnological drug products with regard to toxicological studies, a Scientific Advice at a competent authority may be advisable. This ensures that the chosen preclinical study programme will be acceptable when submitting the IMPD for clinical studies. A Scientific Advice meeting at a competent authority needs careful preparation. The authorities expect that the applicant only discusses those questions that are not 15
16 Regulatory Compliance 16 covered by regulatory guidelines. Early involvement of an experienced regulatory specialist is strongly recommended in order to maximise the company s benefit from such meetings. What is important with regard to clinical studies? Protection of the people enrolled in a clinical study should be of highest priority. Toxicological results from preclinical studies should therefore be the basis for dose finding and implementing safety measures. This is particularly important for highly effective drug products, and special guidelines exist for these kinds of products, all of them focussing on enhancing drug safety, i.e. assessing potential risks and implementing measures for a safe use. Since very often a case-by-case approach is necessary, experienced regulatory specialists can help enhancing interpretation of these guidance documents. The study design of clinical studies is no trivial task and requires a certain amount of experience. The relevant patient population, suitable study endpoints, and the location for the study need to be chosen. Clinical studies with conceptual weaknesses should be avoided as these may fail to demonstrate the efficacy of the drug product. A Scientific Advice with a competent authority may prove useful to ensure acceptance of the study during drug product authorisation. Quality management during conduct of the clinical study is most important and should be surveyed by experienced experts. This includes e.g. monitoring of the study and process audits. Study results have to be adequately processed and study reports have to be compiled following the relevant regulatory requirements. Since many clinical studies are conducted within classical research environments, the awareness towards regulatory requirements with regard to data documentation and reporting should be sufficiently supported. Current studies not being conducted and reported according to GCP/ICH requirements will not be accepted as pivotal data and may not even be considered as supportive data. Moreover, one should be aware of the fact that when developing a new drug product the potential use in children needs special consideration, which requires approaching early the paediatric committee and, usually at the end of Phase I, submitting a Paediatric Investigation Plan (PIP). What are the requirements regarding data documentation? Complete electronic submission in ectd structure is required for EMEA submissions within the centralised procedure from July 2009 onwards, and also for submission to national authorities (e.g. within a decentralised procedure (DCP) or a mutual recognition procedure (MRP)) electronic submission is increasingly required. This poses additional and complex demands on document preparation. It makes sense to put all data in a central repository already at an early stage during drug development. All data will then need to be processed in accordance with ICH ectd requirements. This means, for instance, the use of a certain file structure and certain file names, the creation of searchable pdf files, bookmarking and tagging, and the use of defined hyperlinks and cross-references. Use of that database can already be made for the IMPD and later for preparation of the files for marketing authorisation. What post-approval activities are required? The risk management plan that must be submitted with the application for marketing authorisation describes the risk management system chosen for the specific drug product. This includes post-authorisation studies (Phase IV studies) with much larger patient populations in order to further evaluate the risk-benefit ratio of the new drug product as well as all pharmacovigilance activities planned. Risk management is a continuous process throughout the life cycle of a medicinal product and requires timely planning, involving regulatory expertise. Complex and continuous safety data management according to legal stipulations and regulatory standards is necessary within the pharmacovigilance activities including e.g. safety signalling, database searches, CIOMS and E2B reporting. This requires access to relevant data bases and certain technological equipment which may not be profitable for smaller companies. Therefore various possibilities exist to outsource certain or all pharmacovigilance activities. Conclusion To speed up the entire drug product authorisation process, regulatory compliance should be ensured as early as possible and at all relevant steps of the drug product s life cycle. This includes the areas pharmaceutical quality, preclinical and clinical studies, data documentation and post-authorisation activities within the risk management system. Integration of a regulatory full-service provider proved to be one factor of success for small and medium sized enterprises (SMEs) and should be sought as early as possible during the development in order to ensure a lean development process and an early market entry.
17 Formation of Winning Teams sterna biologicals is a young entrepreneurial company dedicated to the development of third generation anti-sense therapy for the causative treatment of chronic inflammatory diseases, in particular bronchial asthma, atopic dermatitis and rheumatoid arthritis. Based on more than a decade of biological and medical research sterna was founded as a spinoff of the Department of Clinical Chemistry and Molecular Diagnostics at the Philipps University of Marburg and the TransMIT GmbH - Center for Immunomodulation (an institution promoting the transfer of academic research results into economic applications). sterna biologicals has established a novel class of therapeutic compounds for the key indications bronchial asthma, atopic dermatitis, and rheumatoid arthritis representing a highly attractive pharmaceutical market. The rationale of sterna biologicals approach for identifying desirable therapeutic compounds is to interfere with the most relevant key events in the disease causing cascade that are responsible for the development of the inflammatory response. This has been achieved by sterna biologicals patented third generation anti-sense molecules, so-called DNAzymes. The novel approach - as the name already indicates - is that these compounds are enzymatically active DNA structures with all the inherent advantages of this type of compound which contrasts well with other anti-sense therapies. This principle has already been successfully proven for the GATA 3 mrna-specific DNAzyme with regard to efficacy, side effects, off-target effects including escalating dose response in a variety of validated animal disease models for acute and chronic bronchial asthma. The key success factors of sterna biologicals are related to the unique mode of action allowing intervention at a point of the natural course of the inflammatory diseases resulting in a causative treatment effect without stimulation or suppression of other immunological mechanisms. The causative effect stems from catalytic elimination/ destruction of mrnas that encode early key molecules in the signaling cascade that cause and maintain each specific inflammatory process. Thus, the cascade is interrupted at the earliest possible point at the origin of the disease. The corporate goal is to develop therapeutic DNAzymes from animal models to Clinical Phase II trials. But especially for a small start-up company it s a long and winding road to get there. First (and big) step is to manage preclinics and file a sufficient and promising submission of the study to the ethics commissions and the regulatory authorities. Biotech Start-ups and Contract research Organizations Forming winning teams A Case Study PD. Dr. Holger Garn, Dr. Joachim Bille Because of the newness of both, class of sterna s therapeutic molecule and therapeutic approach, there was few experience regarding preclinical study outlines as well on the side of service providers (e.g. for toxicological studies) as on the side of the authorities. So we early decided to get the help of an experinced and well established CRO (from Hessen) to achieve our aim: to get as quick and as cost effective as possible into a Firstin-Man study. The experts helped us to structure steps and milestones. Together we prepared for and obtained an invaluable Scientific Advice from the BfArM regarding toxicological studies and currently are preparing another regarding pharmaceutical quality. The CRO-team taught us to plan preclinics from the sight of the needs of later clinical studies (application route, estimation of dosing in man, favoured inhalation device etc.). They helped us avoiding short-term AND longterm costs by concentration on the minimum requirements for an early approval of the Firstin-Man study, but not disregarding necessary preclinical work which may be essential for later clinical phases (e.g. repeated dose toxicology). Summing up, our urgent advice to biotech start ups in the field of therapeutics is to get expert monitoring by an experienced (in the field of clinical AND preclinical studies) contract research organization. Figure: Potential points of therapeutic interference within and outside the cell to block the generation of proteins involved in the inflammatory cascade. Whereas interference at the DNA level is a more hypothetical possibility due to its irreversibility the direct interference with the mrna is the earliest point of action to inhibit the generation of a specific protein. gene knockout gene therapy DNA antisense technologies DNAzymes sirna antisense DNA RNA antagonists small inhibitors decoys aptamers Authors PD. Dr. Holger Garn Dr. Joachim Bille sterna biologicals GmbH & Co. KG BMFZ Hans-Meerwein-Str Marburg GERMANY PD. Dr. Holger Garn Dr. Joachim Bille antagonists mab peptides ligands aptamers
18 Investigator Initiated Trials 18 Investigator-initiated trials Dr. Torsten Arndt, Dr. Silke Busch Academia has been and still is the pool for innovative therapies and clinical trials, which are crucial for medical progress and the development of novel therapeutic concepts. Investigatorinitiated trials (IITs) have a long tradition at University hospitals and represent an important aspect of medical research, translating discoveries made in basic science into novel therapies, new drugs or devices. IITs are clinical studies set off by physicians at academic medical centers. The goal of IITs is to advance and improve existing therapeutic concepts by supporting investigator-initiated research that will enhance the understanding of disease entities and provide clinicians with the most reliable evidence for careful decisionmaking at the bedside. A major advantage of academic translational research, particularly in a hospital setting, is direct access to patients for clinical studies. By contrast, research at pharmaceutical companies is focused on gaining knowledge of a new compound and bringing out new products, however, IITs are patient-oriented and designed to optimize an already known therapy. To further address the benefit for patients, especially in indications with so far unmet medical need, it is crucial to come up with novel innovative therapeutic concepts. These include studies such as diagnostic and therapy optimizing trials, applying modern genotyping and phenotyping methods of important polymorphisms (SNPs), personalized medicine and adaptive study designs, investigating the combination of existing drugs and the development of orphan drugs. Patients will benefit due to early access to novel, innovative therapies that is provided by these dynamic clinical research efforts. Most significantly, IITs represent the clinical translational efforts of academic centers and underline researchers commitment to innovation for patients. Many times IITs address issues with only marginal prospect of revenue, but commonly investigate so far inadequately solved clinical questions and enhance knowledge of particular disease mechanisms. IITs enable uncommitted clinical research and provide an environment for unbiased clinical trials. Of particular note in this respect is the need of adequate public funding. Obtaining funding for research is the greatest impediment. Generally, funding for IITs is provided by public institutions like the Federal Ministry for Education and Research (BMBF), German Research Foundation (DFG) or foundations to support non-commercial, scientifically compelling and innovative clinical research within various fields of interest. However, beside IITs of pure non-commercial interest, some IITs are entirely funded by industry. As the pharma industry continues to struggle to launch new drugs, it has to rely on life-cycle management of existing products to meet economic aims. In this respect, IITs became a tangible asset and are rather regarded as part of a sophisticated product development strategy by the pharmaceutical industry, than a non-profitable, sciencefocused merit. IIT findings not only provide clinical data to expand scientific knowledge of marketed drugs, but also further the extension of on- and off-label use in new indications to reach larger patient groups. Furthermore, IITs generate data for scientific publications and establish fruitful relationships with academic key opinion leaders. Hence, IITs proposing unique applications, possibly leading to new indications for the drug, are willingly funded by the pharmaceutical industry. A main drawback of translational studies and related personalized medicine approaches in industry is the mandatory economical interest, whereas IITs unravel all sophistications of drug profiling narrowing medical applications. Obviously, both interests aren t necessarily mutually compatible. However, commercial and academic research should not be considered as opponents, because both are interdependent and complementary and close ties between both partners should be encouraged. Recently the regulatory environment for IITs has been reformed substantially. The 12th amendment of the German Drug Law (Arzneimittelgesetz, AMG) was implemented to comply with the requirements of the European Union s Clinical Trials Directive 2001/20/EC for all clinical studies on medicinal products. It defines comprehensive administrative legal requirements with regard to academic clinical research with the intention to stipulate and harmonize regulations for clinical research in respect of Good Clinical Practice (GCP). Undeniably, compliance with GCP-guidelines ensures a valid design of the study, reliable data management and monitoring, as well as qualified analysis of study results, therefore enhancing the value and significance of the collected data. More likely, these trials generate reliable data to improve disease understanding and increase confidence in new therapeutic treatments. Therefore, investigators appreciate the importance of methodological rigour. But the increased regulatory burden confronts investigators with almost unsolvable tasks and is regarded to substantially hamper independent
19 Investigator Initiated Trials In addition to the KSRM in Frankfurt the Coordination Center for Clinical Trials (KKS) in Marburg complements the highly competitive environment for compelling science-initiated trials in Hessen. The KKS Marburg belongs to the KKS network of 12 sites throughout the country, funded by the BMBF, as a platform for transparent, patient-oriented development of new drugs and therapeutic principles in Germany. Furthermore, within the KKS network paediatric trials are supported in special modules to enable the conduct of ethiclinical research. Due to the stringent regulations, a basic prerequisite for IITs is adequate assistance of the investigator in fulfilling the regulatory requirements, guidelines and procedures. Planning and implementation of an IIT demands specialized knowledge of regulatory issues, drug safety and quality management. In this respect, performing an IIT according to the new legal environment requires a service for clinicians and academic researchers to tackle the increased regulatory obligations. It requires professional organisational structures, a highly trained staff and close cooperation with specialised experts, such as project managers, statisticians, data managers, pharmacists and monitors. Based on the emerging recognition of the value of non-industry originating studies, the structures and resources for investigator driven trials in academia are increasingly provided, especially through translational medicine centers like the Center for Drug Research, Development and Safety (Zentrum für Arzneimittelforschung, -Entwicklung und Sicherheit, ZAFES), leading to the implementation of centralized service institutions. Clinical Trial Center Rhine-Main (Klinisches Studienzentrum Rhein-Main, KSRM) The KSRM, as an integral part of ZAFES, provides a competent staff, the expertise and efficient management structure regarding the conception, implementation and monitoring of clinical studies to support independent patient-oriented clinical research by physicians. The KSRM was supported by a triennial grant of the Hessen Ministry of Economics, Transportation and Regional Development (Hessischen Ministerium für Wirtschaft, Verkehr und Landesentwicklung, HMWVL) in order to implement a sustainable infrastructure for clinical research in the Rhine-Main region. The network build up by the KSRM integrates mainly university teaching hospitals, but is in principle open to all regional hospitals and physicians in private practice and therefore provides a large patient pool crucial for considerably faster execution of clinical studies. Notably, the in-house Phase I unit provides capacities customized for most Phase I trial designs, continuous safety monitoring and is backed up by the cooperating hospital emergency care unit, to assure a high degree of individual medical care for all trial subjects. Within this setting there is the option to conduct first-in-man trials, bioavailability/ bioequivalence and PK/PD studies, to rapidly translate therapeutic concepts from the laboratory to the clinic. The KSRM guarantees a close contact to opinion leaders in the respective field and substantially contributes to the competitive position of the Frankfurt region in the field of clinical research. The KSRM aims to represent a balanced portfolio of both innovative publicly funded IITs and clinical trials on behalf of sponsors from the pharmaceutical industry, the latter to continuously benchmark quality measures against industry standards. Coordination Centers for Clinical Trials (Koordinierungszentren für Klinische Studien, KKS) 19
20 Investigator Initiated Trials Authors Dr. Torsten Arndt Dr. Silke Busch Zentrum für Arzneimittelforschung, -Entwicklung und -Sicherheit (ZAFES) Theodor-Stern-Kai Frankfurt am Main GERMANY Phone Fax cally sound and qualified drug trials with children, to counteract the common practice to translate results from studies with adults to children, often inadequately taking into account the unique pharmacology of children. In addition to that, the KKS network is engaged in the organisation of training and further education in the areas of clinical pharmacology, investigator courses, study nurses, documentation, quality management, regulatory guidelines, monitoring, data management and biometrics. ZAFES Excellent academic networks are the key for innovative drug discovery and development projects. Academic medical centers can actively promote the discovery and development of novel drugs by combining their expertise in basic and clinical science with the know-how of pharmaceutical and biotechnology companies. To effectively manage this interface, ZAFES was launched at the Goethe University of Frankfurt integrating hospitals and academic centers to develop, manage, and implement corporate alliances, design the optimal structure for cooperations, negotiate actual partnership agreements and provide project management for collaborative projects. ZAFES implemented a structure to collect, integrate, and disseminate the intellectual, organizational, and resource infrastructure needed to promote and support multidisciplinary research collaborations, being considered to be a key factor for successful translational research. The ZAFES platform promotes university research ideas and inventions, expands and manages industry-academic collaborations and accelerates the translation of biomedical research into therapeutic applications to rapidly deliver new drugs to the patients. In addition the KSRM enables researches to evaluate a scientific rational in a clinical research setting seamlessly, thus supporting a bench to bedside approach. Furthermore, ZAFES trains the next generation of clinical and translational researchers and creates an environment in which investigators have a clearer career path in the highly rewarding discipline of translational research. ZAFES is a partner for the pharmaceutical industry und biotech companies for joint-projects at all stages of the value chain of drug discovery and drug development and provides essential academic core technology facilities. In conclusion, there is a continuous need for conducting IITs to assess novel and complex therapeutic concepts to enable evidence based decision-making in medical care, whether in a completely independent manner funded by public grants or sponsored by the pharmaceutical industry. As compared to international standards clinical research in Germany is only mediocre regarding number of scientific publications, quantity and impact of clinical studies across the board. There is a distinct awareness to substantially further expertise in clinical research and effectively counteract the increasing allocation of clinical trials abroad. Therefore it is of strategic interest to address the establishment of the required infrastructure for clinical research and continuous education and training of physicians in the field of study concept development, coordination and regulatory processes. Of particular note in this respect is Hessens special position, because the large number of resident pharmaceutical companies, biotech firms and CROs along with a vital academic research environment represent a unique cluster for compelling biomedical research and constitute the driving force for novel, innovative medical therapies. Dr. Torsten Arndt Dr. Silke Busch
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